2.0 Analysis 2.1 Personnel Certification The operator held a master's certificate for small craft that was renewable on a yearly basis. However, his certificate was not valid at the time of the accident. A notice regarding the renewal of his certificate had been sent to him in 1990 by the Ship Safety Branch of the CCG. The notice informed him that his certificate had been renewed four times, and that, this time, he would have to contact a Ship Safety examiner to set a date for an oral examination of a practical nature in order to renew his certificate. The operator did not comply with this notice from the CCG and he ignored the requirement to take an oral examination to renew hiscertificate. At the start of each navigation season, the employer had asked the operator if he held a valid certificate; the operator had replied that everything was in order. Furthermore, the operator's most recent certificate was endorsed as follows: This certificate is only valid in pilot vessels not employed in commercial towing operations and operating on the St.Lawrence River between St.Nicholas and St.Jean (Orleans Island) P.Q. 2.2 Certification of the VZINA NO.1 Although the terms service vessel and service boat are not defined in the Canada Shipping Act or the regulations made pursuant thereto, the terms are used in marine technical manuals and recognized marine dictionaries. The definitions given for these two terms are significant: service boats/vessels are defined so as to include pilot boats, linesmen's boats, tugboats and supply boats. Given the results of the TSB stability analysis, there is no reason why the VZINA NO.1 should not have engaged in towing operations on an occasional basis. However, it was the owner's responsibility to ensure that the vessel was crewed and equipped to accomplish these tasks safely. 2.3 Manoeuvre Undertaken by the VZINA NO.1 The VZINA NO.1 initiated the turn to port to move to the desired position, and when she was perpendicular to the tow, the tow-line became taut, the vessel became girded on her starboard side, and her manoeuvrability was reduced. During the towing operation, the doors to the wheel-house were secured in the open position, and this contributed to the downflooding, loss of stability, and capsizing. 2.4 Tow-abort in Emergency Situations In this occurrence, the eye of the tow-line had been hooked over a towing bitt instead of the line being rove round the bitt; this is not normal practice, and is even to be avoided in towing operations. In towage practices, it is essential to keep control of the tow-line at all times, whether to slacken it or make it taut, and to be able to release the tow-line at all times. Tugboats are typically fitted with an automatic tow-abort mechanism which can be activated from the wheel-house. The VZINA NO.1 was not so fitted, nor was she required to be. The service vessel had a fire axe on board to be used to sever the tow-line in case of emergency; however, events unfolded so quickly that the fire axe could not be used in this occurrence. None of the crew members of the CAVALIER MAXIM had remained near the attachment point to release the tow-line in case of emergency. Ship Safety Bulletin No.13/94, entitled Towboat - Dangers Associated with Girding, advises owners and operators of the hazards associated with towing operations. It points out, among other things, that crews must remain constantly vigilant during such operations. In addition, investigations conducted by the TSB in recent years into the causes of the girding and subsequent capsizing of tugboats have raised concerns about the frequency of such occurrences. Witness statements and other information collected in the course of these investigations indicate that, once girded, tugs capsize so quickly that crew members do not have the time to operate the tow-abort control or use the available life-saving equipment. This has been a recurring feature of these occurrences. 2.5 Search and Rescue Although SAR units of the CCG arrived promptly on the scene and the body of the operator was recovered by divers who arrived some time later and attempted resuscitation, nothing done was able to save him. Once they are on the scene of an accident, divers need to observe the site, assess the risks, plan the dive and follow safety procedures before entering the capsized vessel, and this can occasion delays. Had CCG divers been carried on board the STERNE, the outcome would not have been different. 2.6 Death of the Operator The sudden capsizing of the VZINA NO.1 would have thrown the operator off balance and induced stress in a critical situation. The rapid sequence of events, the sudden immersion of the victim, the fact that he was not a good swimmer and the reduced visibility once the vessel had capsized are all factors which may have contributed to the operator becoming disoriented and being unable to exit the wheel-house. Investigations have revealed that some individuals who were known to be good swimmers lost their lives because they became disoriented on entering the water in an emergency situation. 3.0 Conclusions 3.1 Findings 2. The VZINA NO.1 meets all stability requirements of the STAB.3 standard of the Stability, Subdivision, and Load Line Standards. 3. The tow-line between the CAVALIER MAXIM and the VZINA NO.1 was too short and the angle between the attachment points too steep for the intended turning manoeuvre. 4. The crew of the VZINA NO.1 took the eye of the tow-line on board and hooked it over the towing bitt in the middle of the afterdeck. 5. The VZINA NO.1 was not fitted with an automatic tow-abort mechanism to release the tow-line in case of emergency. 6. The VZINA NO.1 remained perpendicular to the tow after initiating a 180-degree turn to port. 7. The two doors of the wheel-house were secured in the open position during the towing operation, and this contributed to the downflooding. The non-watertight wheel-house floor plating was over the engine compartment. 8. None of the crew members of the CAVALIER MAXIM had remained near the attachment point during the towing operation. 9. Search and rescue (SAR) units arrived promptly on the scene. Attempts at resuscitating the operator, who had remained in the wheel-house, were unsuccessful. 10. Had divers been on board the STERNE, the outcome would not have been different. The autopsy report established that death was by drowning. 11. As the operator sustained no head injury, the rapid sequence of events accounts for the fact that he became disoriented and was unable to exit the wheel-house. 12. Neither the Canada Shipping Act nor its regulations contain a definition of the terms service boat or service vessel. 3.2 Causes 4.0 Safety Action 4.1 Action Taken 4.1.1 Rescue Diving Capability Following the collision between the tug ARCTIC TAGLU and the fishing vessel BONAVISTA (TSB Report No.M93W1050), the Canadian Coast Guard (CCG) reviewed its diving policy and embarked on a two-year rescue diving pilot program to determine the effectiveness of rescue diving. CCG rescue divers have completed their training and the pilot program is operating out of the CCG Hovercraft Base Sea Island, in Richmond, BritishColumbia.